Strengthening Public Health Capacities and Services in Europe: A Framework for Action

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1 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE WELTGESUNDHEITSORGANISATION REGIONALBÜRO FÜR EUROPA ORGANISATION MONDIALE DE LA SANTÉ BUREAU RÉGIONAL DE L'EUROPE ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО First meeting of the European Health Policy Forum for High-Level Government Officials / Andorra la Vella, Andorra 25 February 9 11 March 2011 Original: English Strengthening Public Health Capacities and Services in Europe: A Framework for Action Interim draft This working paper is submitted to the European Health Policy Forum for High-Level Government Officials, Andorra La Vella, Andorra, 9-11 March 2011 for comments and suggestions as the interim document in the process of developing a European Framework for Action to Strengthen Public Health Capacities and Services in Europe. This paper and the comments received during the meeting of the Forum will then be submitted to the Standing Committee of the Regional Committee (SCRC), on March 2011, in Copenhagen. This paper will accompany the European Health Policy, Health 2020, and following guidance received from the SCRC, they will both be submitted to the sixty-first session of the Regional Committee (RC61) for discussion, and to RC 62 for approval. It is proposed that this technical paper and annexes will be followed by a focused Action Plan to accompany Health 2020, which will be submitted to RC61 for consideration and to RC62 for final adoption. Thus it forms part of a wider process to develop a European framework for action to strengthen public health capacities and services in all Member States. The document outlines some of the major challenges to health policies and systems in the WHO European Region, including consideration of public health services and infrastructures. In view of the differences in the way European health systems and public health services are organized, operated and governed, the paper makes a clear statement on public health and health systems, including definitions, boundaries and concepts. The paper proposes a set of ten horizontal essential public health operations (EPHOs), and sets out the core public health services within each of them. These will become the unifying and guiding principles for any European health authorities monitoring, evaluating or setting policies, strategies and actions for reforms and improvement in public health. The paper highlights the major avenues that the WHO Regional Office for Europe intends to take in order to tackle public health and health system challenges. It concludes by proposing specific actions and measures to move towards the attainment of the objectives set. This technical paper has been developed through a process of external and internal consultation initiated by the Regional Director. An annex contains a list of the proposed ESPOs, which were prepared in consultation with all Member States and a number of external partners, and have been piloted by 17 Member States since 2007.

2 Contents Page Introduction: mandate...1 Background...1 Scope and purpose...1 Challenges...2 Challenges to health and equity...2 Challenges to societies and health systems...3 Challenges to public health capacities: the current situation in Europe...3 Potential for health gains...3 Introduction...3 The determinants of health...4 Guiding principles: Definitions of public health, essential public health operations for Europe, and health systems...5 Definition of public health...5 Definition of health systems...5 Primary health care and specialized health care services: the link with public health...7 Public health governance...7 Essential public health operations (EPHOs) and policy instruments...8 Framework for Action...9 Concept...9 Strengthening regulatory frameworks for protecting and improving health...10 Improving health outcomes through health protection operations and services...11 Improving health outcomes through disease prevention operations and services...12 Improving health outcomes through health promotion operations and services...13 Assuring a competent public health workforce...15 Developing Research and Knowledge for Policy and Practice...16 Organizational structures for public health services...17 The way forward: WHO s role and next steps...19 References...20 Annex 1: (Unedited) Definitions of Essential Public Health Operations and Services in Europe...20 Annex 2: Wicked problems and systems thinking...50

3 page 1 Introduction: mandate 1. Since the end of the 20th century, Europe has faced complex health challenges (1), including deteriorating health status and widening inequalities among and within countries. Public health as a discipline, and public health services, have also faced unprecedented problems and in some cases have been prevented from developing owing to a lack of political vision and commitment. 2. The resolution entitled Addressing key public health and health policy challenges in Europe: moving forwards in the quest for better health in the WHO European Region (EUR/RC60/R5) (2), which was adopted at the sixtieth session of the Regional Committee for Europe (RC60) in Moscow in September 2010, endorsed the Regional Director s proposal to formulate a new European policy for health, now known as Health Health 2020 will reflect a renewed commitment to public health, with a considerable emphasis on prevention, while at the same time advocating for stronger health systems and the appropriate development of national health policies and strategies. 4. The resolution sought, in particular, to strengthen public health capacity and services, including prevention, and carry out a thorough review of the effectiveness of available public health instruments, as main avenues for addressing key public health and health policy challenges in Europe. The Resolution requested that the Regional Director renew the focus on public health capacity, function and services, and make a real commitment to, and investment in, prevention and health promotion. The present report will accompany the new European policy for health, Health 2020, and will be submitted in preliminary form to RC61 in September 2011 and in a consolidated form to RC62 in September The background to this framework is described in document EUR/RC60/SCRC/18 (3). Background 5. There is no comprehensive and common understanding of what constitutes public health and public health services. Skills and infrastructure across the European Region are patchy, and there is still a long way to go in many Member States before public health infrastructure and practice can be considered strong enough to meet contemporary challenges. The monitoring and evaluation of public health services in European countries, which can facilitate appropriate policy-making, resource allocation and strategies for reform, are lacking or insufficient. 6. The new policy framework, which will be developed in the context of Health 2020, represents a unique opportunity for Member States to review the existing capacities and services for public health as the basis for a much stronger public health function in Europe. The WHO Regional Office for Europe will encourage all Member States in the Region to make strengthening public health services a priority, and will assist them in attaining that goal. Scope and purpose 7. The present technical document aims to put public health and public health services high on the political agenda of ministries of health, and other sectors as necessary, to promote the integration of essential public health operations into national health systems, and to foster public health leadership.

4 page 2 8. Public health leaders must initiate and inform the health policy debate at the political, professional and public levels, in order to advocate for policies and action to improve health. Public health services offer a mechanism for giving expression to health across the whole political and administrative policy-making spectrum. They must take a comprehensive, horizontal view of the health improvement needs of society as a whole, and they must analyse broader strategies for health, create innovative networks for action among many different actors and be catalysts for change. 9. If public health is to be at the centre of health improvement then public health operations, capacities and services must be strengthened. This requires a clear definition of the role of public health, together with its working concepts, boundaries and interrelationships. It is also important that essential public health operations (EPHOs) are defined and performance measured. 10. It is not sufficient, however, to fully integrate public health and health care structures. A good link with social services is essential, particularly to address challenges caused by the ageing and dependent population. Moreover there are many other political, economic, environmental and institutional actors whose activities influence health. A key element in bolstering public health is to integrate its principles and services more systematically into all parts of society through increased whole-of-government and intersectoral working, through a Health in All Policies approach and through participation, transparency, communication and accountability. Challenges Challenges to health and equity 11. The European Region faces multiple health challenges. Despite recent improvements, major health inequalities remain both within and between countries in the WHO European Region. Notably, there is a difference of 20 years for men and 12 years for women between the highest and lowest national average life expectancies in the Region (4). Health experience also varies considerably according to socioeconomic experience and advantage. Evidence shows that most of these inequalities could be avoided. Action is needed to address the significant human and economic costs associated with pronounced health inequalities (5). 12. The most significant challenge comes from an epidemiological shift: the vast majority of the disease burden across the region is now caused by chronic noncommunicable diseases, which accounted for more than 85% of the 9 million deaths in the European Region between 2003 and 2007 (6), and include cardiovascular diseases, cancers, diabetes, chronic lung diseases and mental disorders. Noncommunicable diseases constitute the greatest current health challenge in the Region, to which public health capacities and infrastructure have, thus far, responded inadequately. 13. Communicable diseases also present an increasing challenge for policy-makers and public health institutions and professionals. The need to prepare for different strains of influenza, potential new pathogens such as severe acute respiratory syndrome (SARS) and new drug-resistant strains of tuberculosis mean that communicable disease surveillance and response remain key considerations for public health services. 14. Finally, these challenges are occurring in an extremely dynamic social and political context, in which globalization, economic considerations, technological advances, persistent health inequalities and access to information play an increasingly important role.

5 page 3 Challenges to societies and health systems 15. Existing challenges are also being exacerbated by demographic changes (ageing population and migration). Today less than 17% of the population is aged below 15 years, while nearly 16% is aged over 65. The total dependency ratio in the WHO European Region is expected to increase from 47% in 2007 to 74% in 2050 (7). The ageing population poses a new challenge for public health, the implications of which are fundamental to the viability of Europe s health and social welfare systems, and to the performance of the economy. Cost of illness studies, for example, have estimated that the cost of chronic diseases and their risk factors could amount to as much as 6.77% of GDP in some countries (6). 16. The main challenges continue to be balancing the allocation of resources across sectors according to national priorities, as well as reducing costs and improving health system performance to ensure that investments result in improved health, access, equity and responsiveness. Average health expenditure as a proportion of GDP in the WHO European Region rose from 7.3% in 1998 to 7.7% in 2005 (7). The public sector has shouldered the majority of that burden, and the share of total government expenditure allocated to health care has increased. These challenges are being exacerbated by the current situation of economic and financial crisis, in which the most vulnerable must be protected (8,9). Challenges to public health capacities: the current situation in Europe 17. Although strong public health capacities have historically been vital for meeting all these challenges, investments in this field have been insufficient (10,11,12,13). Recent outbreaks of poliomyelitis and measles in the WHO European Region, owing to gaps in immunization coverage, have highlighted the need to strengthen public health capacity and services, as well as the need for financial resources to be made available to respond to future outbreaks (14). 18. Disease prevention and health promotion are particularly important elements of public health. In a number of countries of the European Region these have become institutionally and functionally lacking as a result of weaknesses inherited from the past as well as recent reforms and structural changes, such as decentralization and privatization of health care services, conducted without appropriate planning and investment in preventive services. The development of primary health care services will enable these elements to function more effectively. 19. The share of health expenditure allocated to public health programmes remains relatively small. Available data, which comes mainly from western European countries, shows that on average, 2.9% of health spending is allocated to public health (15). Potential for health gains Introduction 20. WHO still faces considerable challenges to meeting its objective of the attainment by all peoples of the highest possible level of health. Yet it is possible to be optimistic. Health has improved both globally and in the European Region in recent decades: life expectancy has increased and technological advances in modern medical science have revolutionized opportunities for the prevention and control of disease among the population as a whole, and at the individual level. 21. Despite these advances health related inequality persists between and within countries, stratifying populations according to ethnicity, gender, socioeconomic status, education, and

6 page 4 geographical location. The differences are not caused by health care systems and access to these systems alone, but also by the political, institutional, social, economic and environmental circumstances of peoples lives. This inequality affects the very core of the human right to health. 22. To build on past successes and improve population health in an equitable way, we must strengthen health systems and renew political commitment to evidence based public health services and infrastructures, which must be appropriately integrated into health care structures. The determinants of health 23. The determinants of health are multiple and varied. Political, social and economic circumstances are extremely influential, and the report issued by the Commission on Social Determinants of Health (CSDH) (5) in 2008 demonstrated the ethical imperative of acting on inequalities in the distribution of power, influence, goods and services, as well as in living and working conditions and access to good quality services, including health care, schools and education. 24. Environmental factors also influence health. They include water and air quality, environmental pollution caused by hazardous substances and emissions, urbanization, climate change, rising temperatures and sea levels, and an increased frequency of natural disasters and extreme weather conditions. 25. Behavioural determinants such as smoking, alcohol, diet, exercise and substance abuse also have a significant impact on health, particularly in relation to the rising prevalence of noncommunicable diseases. Increased investment in the preventive portfolio within primary health care may be particularly useful to address this fact, keeping in mind that although there are countries where this is not currently the case, primary health care can and should be interpreted in a broad sense to include health promotion and disease prevention. While some efforts to tackle smoking prevalence have been successful, an effective package of health interventions that addresses all of these risks should be developed in the context of a strategy to deal with the surging burden of noncommunicable diseases. 26. Finally, the capacity and efficiency of health systems is an important health determinant. At the moment it is generally considered that socioeconomic determinants have a greater influence than health system capacity on disease incidence, although over the course of a disease trajectory, health systems play an increasingly essential role in determining health outcomes. In that sense strengthening health systems (including their advocacy role outside the health care sector) will be an important component of Health The issue facing Member States in the European Region is how to improve performance and reduce costs while maintaining the European values and principles agreed in Health for All, HEALTH21, and the Tallinn Charter, namely solidarity, equity and participation (16,17,18). 28. These determinants are inevitably interrelated. Many of them are amenable to effective interventions. Increased investment in health promotion and disease prevention is essential; awareness should be raised about the economic costs and benefits of prevention. Prevention includes population based vaccination programmes, but also the early detection of disease, such as hypertension and some cancers that are amenable to early treatment. Health promotion programmes aim to improve lifestyle and behaviours through education, advocacy and support offered to the population by health services and other sectors such as education and labour. More efficient therapy and rehabilitation are also required for those affected by disease.

7 page 5 Guiding principles: Definitions of public health, essential public health operations for Europe, and health systems Definition of public health 29. A core definition of public health has proven elusive (19). Definitions vary depending on whether they are framed by the public health function and activities related to a public health workforce; whether they are normative or descriptive; or whether they incorporate wider social and economic factors influencing population health and health inequalities. From a pragmatic perspective a general definition is required, which may be used as a basis for describing in more detail the core activities of the public health function, but which is also sufficiently flexible to allow for debate on broader interpretations of what is involved in improving the health of the population in a given context and at a particular time. 30. After considerable internal and external consultation. The definition of public health originally put forward by Winslow in 1920 (20), and adapted by Acheson in 1988 (21), has been widely accepted, and is proposed for adoption: Public health is the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society Sir Donald Acheson This definition has important characteristics. It is intentionally generic and does not specify particular societal preoccupations for public health outcomes, which might change over time. It refers to public health as both a science and an art, essentially and always a combination of knowledge and action. Public health must have an evidence base, but action must be taken on the basis of current knowledge. The core purposes of public health are to prevent disease, prolong life and promote health. Public health is an organized societal function. Several important and implicit aspects of this definition should be highlighted and explicitly communicated when necessary, including: health protection outcomes such as wellness or quality of life individual responsibility and choice future orientation of public health political empowerment, equity and human rights in relation to health, and the importance of health systems for public health improvement, including the key public health responsibility of ministries of health, rather than their simply being managers of the health care system. Definition of health systems 32. The following definition of a health system, presented and adopted in the Tallinn Charter in 2008 (18), is proposed to be retained. Within the political and institutional framework of each country, a health system is the ensemble of all public and private organizations, institutions and resources mandated to improve or restore health. Health systems encompass both personal and population services, as well as activities to

8 page 6 influence the policies and actions of other sectors to address the social, environmental and economic determinants of health. Tallinn Charter, WHO Europe, Acheson s definition makes it clear that public health is a function of the whole of society, to be achieved through society s organized efforts. Public health goes beyond the strict boundaries of the health sector, encompassing a wide range of stakeholders throughout society. At the same time, the health system (led by the Ministry of Health) is absolutely central to public health leadership and services. Thus, public health is also about health systems, and reciprocally, health systems can only be effective if they include a public health services component. 34. In the public mind health systems remain largely associated with health care systems which, unlike public health systems, have relatively clear organizational boundaries, are familiar, and are highly visible and valued by populations. 35. The health system can be conceptualized as a key channel for the organized efforts of society in terms of public health and health improvement (see Diagram 1 below). The Diagram shows the health system in turquoise, and includes institutions and organizations with a health mandate, the resources dedicated to health, and the services delivered to promote, protect and restore health. The governance function orchestrates and aligns the numerous efforts from the different sectors of society in order to maximize health gain. We need to keep in mind that public health services must be strengthened to improve health as a whole, since they are fundamental to the health of the whole population. An investment in public health is an investment in long term health and well-being, which is not only of value as a good in itself but also as a contributing factor to economic productivity. Fig. 1: Conceptual framework of the boundaries of public health and the health system Health To promote, protect, restore health Services delivery Governance Dedicated to health Ressources Health mandate Institutions/organizations Society (individuals, families, communities) Environment

9 page This diagram conceptualizes public health as a broad societal function, including organizations, resources and services from the health system, but also from other sectors of society, constrained only by the boundaries of society s organized efforts. There are also a myriad of other societal activities influencing health, but which cannot be said to be part the organized efforts of society. Primary health care and specialized health care services: the link with public health 37. The Declaration of Alma-Ata (1978) defines primary health care as essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally acceptable to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. Primary health care addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly. 38. Primary health care is a fundamental part of the health care system (22), which should work hand in hand with public health services to pursue health gain. It is important to highlight the fact that the primary health care services portfolio includes disease prevention and health promotion activities. It is therefore one of the main instruments for integrating public health into the wider health care system, as a primary vehicle for prevention, and as a nexus for all branches of the health system. 39. Other specialized health care services should be properly linked to public health services. It is important to break the barriers between traditional health care services and traditional public health activities; to articulate primary and secondary prevention functions in both primary and specialized health care; and to provide bidirectional informational tools for appropriate health surveillance, using a coherent system approach. Public health governance 40. New approaches to health governance are required to ensure a better understanding of the complex interplay between the various determinants of health, in particular the role of economic and social factors and ways in which resources and influences are distributed across society. A key premise is that multiple determinants must be addressed using cross societal and joined up government approaches with the involvement of multiple sectors and stakeholders. This is the basis of Health in All Policies (23). 41. As noted earlier, many of the most pressing present and future policy challenges affecting public health involve addressing complex problems, such as climate change, obesity and health inequalities. These problems, which are known as wicked problems, go beyond any one organization s capacity to understand or address. There is often disagreement about the causes of such problems, and a lack of certainty about the best way to tackle them (24). Wicked problems are described more fully in Annex 2.

10 page As part of the development of Health 2020, the WHO Regional Office for Europe has commissioned a study on governance for health in the 21st century, to contribute to Health 2020 and the strengthening of public health infrastructure, capacity and practices. Essential public health operations (EPHOs) and policy instruments 43. The background to developing essential public health operations (EPHOs) has been developed across the WHO European Region. The EPHOs, of which there are 10 at present, are a work in progress and are currently being used in a self assessment programme in the European Region. The 10 EPHOs are described in detail in Annex 1, and can be summarized as follows: surveillance and assessment of the health and well-being of the population; identification of health problems and health hazards in the community; preparedness and planning for public health emergencies; health protection operations (environmental. occupational, food safety and others); disease prevention; health promotion; evaluation of quality and effectiveness of personal and community health services; assuring a competent public health and personal care workforce; leadership, governance and the initiation, development and planning of public health policy, and public health research. 44. EPHOs should be updated in light of the changing European context. They should be mapped against the WHO health system framework and the Tallin Charter, and against existing public health services. The concepts presented in the EPHOs, such as equity, transparency, accountability, governance and stewardship, should be clarified. There should be consistent use of terminology during the process of strengthening public health across the European Region and to that end the new European policy for health, Health 2020, should include a glossary of terms. 45. A web-based self-assessment tool for public health has been developed, based on the EPHOs. It has been used in countries to evaluate the current state of capacity and practice related to EPHO implementation. Following a strategic analysis, the tool highlights the strengths and weaknesses, as well as necessary and proposed actions for further development. Areas identified for improvement include: issues of governance (legislative development or governmental leadership), health financing, resource generation (human, technological or knowledge), or service delivery. This matrix approach allows the integration of vertical (services and operations) and horizontal issues. An added value of the tool is to bring different public health stakeholders together to reach consensus, as well as to promote progress by allowing continuous assessment. These systemic dimensions (which include governance, financing and resources) encompass a whole-of-government approach which is not necessarily restricted to the health sector. 46. The tool has already been tested in 17 eastern European Countries with positive feedback on its relevance for identifying strengths and weaknesses, as well as for defining strategic actions to improve EPHOs in countries. The tool must still be tested in western Europe, as well as in countries with decentralized public health structures and responsibilities, in order to get comprehensive feedback on its relevance across the European Region. Moreover, there is potential to further focus the EHPOs for better coherence, deleting redundant items and perhaps

11 page 9 adding relevant, new challenges, such as communication for better health. This is intended to be a two-way process of using social marketing to listen to suggestions and reactions, and then engaging in a positive and constructive exchange making optimum use of technologies and developments (including social media). Framework for Action Concept 47. A framework for action for protecting and improving the health of populations should reflect current health challenges and emerging hazards, while at the same ensuring that core public health activities are maintained and resourced. Promoting population health, whether at national, regional or local level, requires action to understand and address the impact on health of a wide range of social and economic determinants while continuing to ensure comprehensive monitoring and enforcement systems for communicable disease control, environmental health (including food safety, water quality and sanitation), occupational health, health protection and access to effective preventive health services. 48. A framework for action should be constantly reassessed and updated, while maintaining a focus on the importance of living and working conditions, education, effective disease prevention and the needs of disadvantaged or socially excluded groups. At the same time, an action framework needs to incorporate plans for addressing future challenges to population health, including sustainability and the impact of current policies on inter-generational equity. 49. A framework for action for protecting and promoting population health inevitably reaches far beyond effective delivery of the public health function in any single state. It involves states working together to promote global public health values and address problems arising from globalization and health worker mobility, including the rapid spread of communicable disease and the impact of global finance, and the challenges associated with global communication strategies. 50. At the national level, a framework for action should be influenced by the extent to which governments endorse a governance role in relation to the health of their populations, and their degree of commitment to human rights, social equity and social justice, and implement policies for sustainability and reducing inequity. At a policy level, it involves fostering intersectoral approaches, considering the impact on health and on health inequalities of a range of policies outside the health sector (singly and in combination), recognizing the potential impact of these policies on health, as reflected in Health in All Policies (23), and ensuring effective governance arrangements and resources for core preventive activities. 51. A framework for action should focus on operational aspects of the public health function while recognizing the wider strategic context within which this occurs and which influences the extent to which implementation is effective. It draws on the 10 EPHOs (see Annex 1). 52. The 10 EPHOs provide a comprehensive checklist of essential public health activities. Priorities for action in the shorter term will vary according to country-specific health challenges and the resources available to states to discharge their public health function. While governance arrangements for the public health function differ between Member States, broad governance principles, such as accountability and transparency, remain constant. 53. A framework for action requires a number of conditions. The health of the population must be explicitly recognized as a key governance role of national government.

12 page 10 National government must support the leading role of ministers of health, working in partnership with other sectors, by securing provisions for different mechanisms in national legislation and regulations. Health strategies and policy priorities should be revised based on an assessment of current health needs, and inequalities in health and equitable access to preventive services should be reduced using the opportunities provided by the new European policy for health, Health Intersectoral action should be supported at the national, regional and local levels to promote concerted action on wider determinants of health. Legal provisions in that regard should be amended to ensure that national and subnational regulations are based on the current European and global experience. Consistency in strategy and direction across different levels of organization should be secured using systems for monitoring performance and ensuring accountability. National and subnational governments should ensure that adequate resources are targeted to delivering essential public health operations, services and activities, including identification of emerging health hazards Strengthening regulatory frameworks for protecting and improving health 54. Regulatory frameworks are complex and multifaceted. Where risks to the health of the population are considered to outweigh other considerations, including individual choice, legislation is the preferred policy instrument. In recent years the use of legally binding arrangements to protect population health has increased. In particular, aspects of environmental health, safety of food and drinking-water, occupational health and infectious disease control have been the subjects of public health legislation. 55. These public health interventions can be highly cost effective. They include actions to reduce alcohol consumption through taxation and advertising bans; legislation to reduce trans fats and salt content in food; tobacco control measures related to advertising, taxation and smoke free workplaces; and road safety through mandatory seat belt use, speed bumps and breath tests. While many of these actions would already be justified for other reasons, the cost effectiveness evidence is a further argument in favour of their implementation. 56. Legislation may be international, such as the Universal Declaration of Human Rights (24), the International Health Regulations (2007) (25) and the Framework Convention on Tobacco Control (2005) (26); regional, such as European Union directives and the Protocol on Water and Health to the Convention on the Protection and Use of Transboundary Watercourses and International Lakes (27); or national, such as national public health laws. A study of public policy instruments for Public Health in the European Region (28) describes a wide range of instruments available to WHO (conventions, regulations, recommendations and standards), reflects variation between countries deployment of specific instruments, and notes changes in national regulatory frameworks arising from a growth in pluralism and democratization. 57. Public policy instruments may also provide technical support to national governments. Compliance with international agreements should be reflected in the assessment of the relevant EPHOs, in order to identify national progress towards meeting internationally agreed standards. A mapping exercise could serve to indicate the EPHOs for which international agreements and guidance are available. 58. While legislation is enforced through legal systems, national governments try to ensure implementation of national health strategies and policies through a range of monitoring, audit and performance management arrangements often associated with meeting standards or

13 page 11 achieving targets. These procedures may be carried out by regulatory agencies, and associated with a range of penalties (and sometimes incentives or rewards). 59. While there is some uncertainty regarding which aspects of performance management arrangements are effective in which circumstances, there is evidence that simple process targets can lead to unintended consequences and gaming. A broader approach is needed, based on performance measurement and accountability mechanisms. A focus on improving both the process and the health outcomes allows for a dynamic local system of accountability, which brings the reactions of the person being held accountable into the frame of reference. 60. For WHO, there has been a movement away from region-wide targets towards an emphasis on countries developing their own national frameworks for performance measurement and accountability to guide subnational priorities and performance assessment frameworks (6). These national frameworks will be built in line with the vision expressed in a national health plan or strategy, or a detailed health reform programme. While the diversity of approaches and variety of contexts should be recognized and lauded as an indication of country ownership, WHO advocates for national frameworks that translate shared values of equity and solidarity and foster transparency. 61. Standards for the delivery of public health services should be made explicit and their quality ensured through regular scrutiny, inspection or assessment arrangements and accreditation. 62. EPHOs provide a detailed and practical basis for performance assessment, enabling Member States to assess infrastructure, performance and capacity related to 10 core public health activities. This will show where gaps exist between the specific public health challenges of Member States and the infrastructure and capacity required to address them. 63. A number of conditions are required to strengthen regulatory frameworks for protecting and improving health. An implementation plan must be in place for legally binding international treaties, conventions and regulations, as well as resolutions and standards related to protecting population health. National regulatory frameworks related to licensing, accreditation and quality control of public health services, including laboratory facilities, should be reviewed in the light of best practices. An implementation plan for national health strategies should be established, including performance assessment measures for the delivery of core public health functions, standards and targets. Effective systems should be in place to ensure the continuous improvement of quality of public health services, with clear lines of accountability. Support should be given to intersectoral and integrated approaches to complex problems. Improving health outcomes through health protection operations and services 64. Assessment of the health needs of populations is the cornerstone of any public health strategy, and guides core public health activities in relation to health protection and promotion and disease prevention, as well as the development of national health strategies. Such assessments can be conducted jointly across agencies and in partnership with local communities. The can influence priorities, service interventions and targeting strategies. Health

14 page 12 needs assessments should be independent and may take the form of a local public health report that is available to the public. Such assessments should be conducted on a regular basis. 65. Health protection requires systems that enable rapid detection, response and communication strategies. Control of communicable diseases remains a core activity for the public health function. This requires vigilance with regard to existing diseases, rapid response to new strains, and maintenance of an infrastructure for identification, control and treatment. There should be an equivalent rapid reporting system for environmental hazards. 66. The capacity to activate emergency plans that have already been tested and mobilize emergency response teams in response to public health emergencies, whether due to natural disasters, communicable disease outbreaks, chemical hazards, radiological hazards or bio terrorism, are fundamental to health protection. There should also be capacity for public health surveillance follow up activities in the aftermath of disasters. 67. A number of actions are required to improve health outcomes through health protection operations and services. Data collection, integration and analysis should be improved in order to support health needs assessments and the rapid identification of emerging risks and hazards. Health needs assessments should be conducted on a regular basis to identify health status and health needs of the population; inequalities in health; changing patterns of disease; and implications for service provision. Reporting mechanisms should be established for disease outbreaks with better coordination across public health, veterinary, occupational and food safety agencies. Capacity and resources to implement IHR should be regularly reviewed. Emergency response plans should be put in place and regularly tested. Improving health outcomes through disease prevention operations and services 68. Primary prevention refers to activities to prevent the manifestation of a disease, while secondary prevention refers to early detection for improving the chances for positive health outcomes. Tertiary prevention aims to re-establish health once the disease appears, applying care or treatment to cure or palliate a disease or its symptoms. Finally quaternary prevention alludes to the group of health care activities carried out to lessen or avert the consequences of unnecessary or excessive health care interventions. 69. Primary disease prevention is, by definition, a broad concept, including health promotion activities that have a positive influence on health-affecting behaviour, and health protection measures that prevent disease (environmental or food safety). However, given that the above functions are explained in detail in other sections, disease prevention can be practically understood as clinical preventive services including immunization and vaccination, evidencebased screening programmes, and the range of screening and preventive measures delivered through maternal and child health services. Preventive services are largely aimed at individuals but require computerized call and recall systems for selected populations and an organized system of delivery that is accessible to those populations. Such services may also involve targeted action to reach groups who are at risk but may not be able to access preventive services. There should be no financial or other barriers to accessing preventive services. 70. Vaccination programmes are widely established with clear guidelines and processes but additional action may be required in certain situations: in the event of inadequate coverage of

15 page 13 the target population; to provide outreach for rural and isolated populations or those unable to access services; when selective media coverage of safety has led to a reduction in vaccine take up and population immunity; to implement catch-up programmes or new initiatives in response to outbreaks of disease; in order to achieve the required level of coverage of influenza vaccine for adults at risk and the older population; to ensure vaccination coverage for marginalized or stigmatized groups; and to encourage vaccination of persons in certain occupations such as staff providing health services. 71. There are great disparities in maternal and child health between European countries. In 2008, infant mortality was reported at less than 5 per 1000 live births in 19 European countries, but at 30 or more per 1000 in each country in central Asia (6). The accessibility of maternal and child health programmes that offer a range of routine preventive and screening services should be evaluated, and reasons for late enrolment should be identified. Targeted approaches may also be required for those who lack access to other preventive services. 72. Evidence-based screening programmes may be established to identify and treat disease in its early stages. Their applicability and operation should be assessed according to agreed criteria related to: the magnitude of the problem; the extent of disparities between populations and geographical areas; the identification of a target population; the availability of laboratory facilities; and the capacity to treat detected cases quickly. A good system of primary health care with a registered population facilitates the optimal organization and delivery of populationbased screening programmes, which should be vigorously promoted in favour of opportunistic screenings without value-added evidence. 73. As well as organized screening programmes there opportunistic case findings by health professionals can occur, as well as evidence-based interventions related to the reduction of risk factors such as smoking, alcohol consumption and poor diet. 74. A number of actions are required to improve health outcomes through disease prevention operations and services. Adequate resources should be allocated to vaccination programmes, including the purchase and storage of vaccines and the maintenance of effective call and recall systems. Evidence based screening programmes should be implemented and regularly updated in the light of best practices. Systems for involving primary care and specialized care in disease prevention should be evaluated. Targeted programmes to reach populations at risk should be developed and evaluated. Maternal and child health services should be accessible and reasons for low or late enrolment investigated. Improving health outcomes through health promotion operations and services 75. The Ottawa Charter (29) sets out five main strategies for health promotion: building healthy public policy; creating supportive environments; strengthening community action; developing personal skills; and reorienting health services. Building on these strategies, the following points reflect key elements of effective health promotion and can be applied across a range of topic areas, such as smoking, obesity or drug abuse. 76. The first priority of public health promotion is the recognition of the influence of political, social, and cultural contexts on life chances and on behaviour at each stage of the life

16 page 14 course has led to an emphasis on different settings and contexts for health promotion activities and on policies for making healthy choices easier by creating health promoting environments (including the use of legislation) as well as partnerships and intersectoral collaboration to address the social and economic determinants of health. This approach is fundamental to addressing inequalities in health and is being addressed in Health 2020 by the European Social Determinants and Health Divide Review. 77. The second priority, which reflects the 1948 WHO definition of health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (30), emphasizes the promotion of well-being, including mental health promotion, as well as disease prevention. 78. The third priority, which is also related to the above, focuses on the resilience of communities as a reflection of the quality of social networks, increased participation in decision-making and active involvement in improving the environment and developing a culture of health. An assets approach to community health and well-being involves building on the cultural and material assets to promote active communities, address inequalities in health and encourage long term change. 79. It has been argued that effective local delivery for challenging health inequalities requires local participatory decision-making (21). This builds on a long standing appreciation of relationships between community development and health promotion, as reflected in the declaration of Alma-Ata, which moved away from professionally dominated notions of primary health care towards a more participative and multisectoral approach. This also involves community participation in planning health promotion activities. 80. The fourth priority, which is related to an intersectoral approach, promotes a public health ethos in different settings and organizations both inside and outside the health care sector and, more recently, through whole area approaches to service provision. While the important role of primary care in providing health promotion and preventive services has been reiterated since Alma-Ata, family doctors often lack the time or incentives to focus on prevention. Access to preventive services in primary care is variable and may not meet the needs of vulnerable or stigmatized groups. 81. Thre fifth priority is the importance of not increasing health inequalities through health promotion activities that are either inappropriate, culturally insensitive or fail to reach those most in need. 82. The priorities for health promotion are informed by key public health challenges as identified through health needs assessments. EPHO 6 outlines key operations in relation to diet and nutrition, physical activity and obesity; tobacco and alcohol control, drug abuse and prevention; prevention of infectious disease, sexual health, occupational health, environmental health and mental health and dental hygiene. 83. A number of actions are required to improve health outcomes by promoting operations and services. Intersectoral dialogue and cooperation between partners should be promoted to develop joint approaches to factors influencing health, well-being and healthy lifestyles. Communities should be involved in decision-making and building on community assets. The appropriateness of health promotion activities for targeted groups and those with the greatest health needs should be evaluated.

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